A 5-Month-Old With Severe Abdominal Distention and Lethargy

Jaime Shalkow, MD; Mayela E. García


November 20, 2019

Physical Examination and Workup

Upon arrival to the hospital, the child looks extremely ill. He is immediately admitted to the ED shock room. He is very pale, flaccid, and unresponsive. The anterior fontanel is depressed, and his skin and mucous membranes are dry. Peripheral pulses (extremities) are not felt, but his carotid and femoral pulses are weak, with evident tachysphygmia. His heart rate is 210 beats/min, his respiratory rate is 45 breaths/min, his blood pressure is 50/40 mm Hg, and his temperature is 96.4°F (35.8°C).

The patient's abdomen is grossly distended, tense, and discolored. Bowel sounds cannot be heard. His alert status does not allow evaluation for rebound tenderness. Capillary refill time is 5 seconds. He becomes unconscious and is intubated and placed on a ventilator. Vascular access is achieved on the left femoral vein, and an intravenous bolus of Ringer solution (10 mL/kg) is given. An arterial line is placed on the femoral artery, and blood gas analysis reveals severe metabolic acidosis with elevated lactate level.

Blood tests reveal a hemoglobin level of 6 g/dL, leukocytosis of 14,000 cells/µL, neutrophilia of 73%, and platelet count of 60,000 cells/μL. Electrolyte analysis demonstrates hyperkalemia (potassium level, 5.9 mEq/L). The patient's blood pressure does not improve after the initial fluid bolus, and he is given a second one. Paracentesis reveals bloodstained free fluid.


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